Drug and Therapeutics

Committee
Session 4. Assessing and Managing
Medicine Safety

1
Objectives
 Describe the significance of—
 Adverse drug reactions (ADRs)
 Medication and prescribing errors

 Understand—
 Principles of medicine safety evaluation
 Management of spontaneous case reports of
ADRs and medication and prescribing errors
 The process of monitoring, evaluating, and
preventing ADRs and adverse drug events
Outline
 Key Definitions
 Introduction
 ADRs—Pre- and postmarketing surveillance
 Causality
 Implications for the DTC
 Adverse Drug Events and Medication Errors
 Activities
 Summary
Key Definitions (1)
Adverse drug reaction (ADR)
 A noxious and unintended response to a medicine that occurs at
normal therapeutic doses used in humans for prophylaxis, diagnosis,
or therapy of disease, or for the modification of physiologic function
 The word “effect” is used interchangeably with “reaction.”
Side effect
 Any unintended effect of a pharmaceutical product occurring at normal
therapeutic doses and is related to its pharmacological properties.
Such effects may be well-known and even expected and require little
or no change in patient management.
Serious adverse effect
 Any untoward medical occurrence that occurs at any dose and results
in death, requires hospital admission or prolonged hospital stay,
results in persistent or significant disability, or is life threatening
Key Definitions (2)
Adverse drug event
 Any untoward medical occurrence that may be present during
treatment with a medicine but does not necessarily have a causal
relationship with this treatment. Adverse drug events include
medication errors and overdoses.
Causality
 The probability that a particular medicine is responsible for an
isolated effect or ADR.
Signal
 Reported information on a possible causal relationship between and
adverse event and a medicine, the relationship being previously
unknown or incompletely documented. Usually more than one signal
report is required to generate a signal, depending on the
seriousness of the event and the quality of the information.
Key Definitions (3)
Prescribing error
 Incorrect medicine ordering by a prescriber

Medication error
 Administration of a medicine or dose that differs from the
written order

Negligence
 Medical decision making or care below the accepted
standards of practice
Introduction
 ADRs and events constitute a serious problem increasing
morbidity and mortality and health care costs worldwide.
 Overall incidence of ADRs in hospitalized patients in the
United States in 1998 was 6.7%, and fatalities were 0.32%.
 Lazarou, J., B. H. Pomeranz, and P.N. Corey. 1998. Incidence of Adverse Drug
Reactions in Hospitalized Patients: A Meta-analysis of Prospective Studies.
JAMA 279 (15):120–25.

 ADRs resulted in approximately 250,000 admissions a year in

the United Kingdom
 Projected costs of ADRs to the United Kingdom’s National
Health Service was £466 million (€ 680 million; USD 870 million)
 Hitchen, L. 2006. Adverse Drug Reactions Result in 250 000 UK Admissions a
Year BMJ 332:1109
 Pirmohamed, M. et al. 2004. Adverse Drug Reactions as Cause of Admission to
Hospital: Prospective Analysis of 18,820 Patients. BMJ 329:15–19.
Adverse Drug Reactions (1)
Patient injury caused by a medicine taken in
therapeutic doses

 Type A—Exaggerated pharmacological response

 Pharmacodynamic (e.g., bronchospasm from beta-blockers)
 Toxic (e.g., deafness from aminoglycoside overdose)

 Type B—Nonpharmacological, often allergic, response

 Medicine-induced diseases (e.g., antibiotic-associated colitis)
 Allergic reactions (e.g., penicillin anaphylaxis)
 Idiosyncratic reactions (e.g., aplastic anemia with chloramphenicol)
Adverse Drug Reactions (2)
 Type C—Continuous or long term (time related)
 Osteoporosis with oral steroids

 Type D—Delayed (lag time)

 Teratogenic effects with anticonvulsants or lisinopril

 Type E—Ending of use (withdrawal)

 Withdrawal syndrome with benzodiazepines

 Type F—Failure of efficacy (no response)

 Resistance to antimicrobials
Determining Medicine Safety:
Identifying and Managing ADRs
 Premarketing clinical trials
 Animal studies, human studies—Phases I, II, III
 Cannot identify ADRs with incidence < 1%
 Unproven ADRs listing for legal protection of manufacturer

 Postmarketing surveillance
 Spontaneous reporting
 Postmarketing clinical trials—Phase IV
 Other methods—observational studies, meta-analysis, case
reports
 Determining causality
 Actions taken to manage new ADRs
Postmarketing Surveillance of ADRs:
Spontaneous Reports
 Best method for detecting new ADRs

 Necessary because many ADRs not detected in

pre- or postmarketing studies

 Initiated by physicians, pharmacists, nurses,

patients

 Problems include underreporting, inaccurate

reporting that may not show causality, and high
false positive rates
Postmarketing Surveillance of ADRs:
Clinical Studies
 Postmarketing clinical studies
 Done to determine efficacy and safety (Phase IV
trials)

 Generally poor in detecting ADRs because—

 RCTs often insufficient for assessing ADRs, so
observational cohort and cases control studies are used
 Nonrepresentative patient selection
 Narrow medicine indications and dosing structure
 Limited concomitant medicine use
Postmarketing Surveillance: Other Methods
 Observational studies provide limited identification of
new ADRs
 Large databases in the United States and Europe from
national health programs, HMOs, health insurance programs
can provide data for case control or cohort studies
 Cohort studies useful for assigning causality

 Published case reports—provide limited information

about ADRs

 Meta-analysis of published papers—provide

identification of new ADRs by increasing the power of
the clinical studies
Actions for Newly Discovered ADRs
 “Dear Doctor” letters—describe a new safety
concern about a particular medicine
 Package insert revisions
 For significant safety concerns
 Manufacturers must change the official labeling and
the package insert to reflect the new safety concern
 Typically approved by the regulatory authority

 Medicine recalls (voluntary and compulsory)

 For serious safety concerns
 May be voluntary or imposed by the regulatory
authority
Determining Causality of an ADR
 Factors in determining causality
 Strength of the association
 Consistency of the observed evidence
 Temporality of the relationship
 ADR that occurs in association with a medicine
does not mean the medicine is responsible
 Delayed reactions do not rule out the medicine as
causing the ADR
 Dose-response relationship
 Confounding factors
Classifying Causality of an ADR
 Certain causality—when a clinical event (including laboratory test
abnormality) occurs in a plausible time relationship to medicine
administration and cannot be explained by concurrent disease or
other medicines or chemicals; re-administration of the medicine
causes a similar reaction

 Probable or likely causality—when a clinical event occurs with a

reasonable time sequence to medicine administration and is unlikely
to be due to any concurrent disease or other medicine administration

 Possible causality—when a clinical event occurs with a reasonable

time sequence to medicine administration, but which could be
explained by concurrent disease or other medicine administration

 Unlikely causality—when a clinical event (including laboratory test

abnormality) occurs in temporal relationship to medicine
administration that makes a causal relationship improbable, and when
other medicines, chemicals, or underlying disease provide plausible
explanations
Classifying Causality of an ADR: Naranjo Algorithm
Question Yes No Do Not
Know
Are there previous conclusive reports on this reaction? +1 0 0
Did the adverse event appear after the suspected medicine was
+2 -1 0
administered?
Did the adverse reaction improve when the medicine was
+1 0 0
discontinued or a specific antagonist was administered?
Did the adverse reaction reappear when the medicine was re-
+2 -1 0
administered?
Are there alternate causes (other than the medicine) that could
-1 +2 0
solely have caused the reaction?
Was the medicine detected in the blood (or other fluids) in a
+1 0 0
concentration known to be toxic?
Was the reaction more severe when the dose was increased or less
+1 0 0
severe when the dose was decreased?
Did the patient have a similar reaction to the same or similar
+1 0 0
Total the
medicines score
in any to determine
previous exposure?the category of the reaction. The categories
Wasare defined event
the adverse as follows: Definite>9;
confirmed Probable
by objective 5–8; Possible 1–4;
evidence? +1 Doubtful
0 0.
0
Implications for DTC Surveillance of ADRs
 Monitoring and managing ADRs requires setting
up surveillance systems
 Use of local surveillance (tracking and reporting)
system run by the DTC
 Use of standardized reporting forms
 Analysis of reported ADRs to be done by selected
DTC committee member
 Reporting of serious and recurring ADRs to
regulatory authorities and manufacturers
Potential Role of DTC in ADR Reporting
Process of reporting to higher facility
and directly to national center National
Pharmacovigilance
Unit
Provincial Hospital
DTC

Health Facility DTC

Local level
Managing ADRs
Step 1. Evaluate the nature of the event.

 Obtain a detailed history of the patient.

 Identify and document the clinical reaction. Look up
suspected medicines and known ADRs in the literature
and match them with the reactions described by the
patient
 Classify the severity of the reaction.
 Severe—fatal or life threatening
 Moderate—requires antidote, medical procedure, or hospitalization
 Mild—symptoms require discontinuation of therapy
 Incidental—mild symptoms; patient can chose whether to
discontinue treatment or not
Managing ADRs
Step 2. Establish the cause.

 Use the Naranjo algorithm (or other system) to

assess the patient’s reaction.

 Evaluate the quality of the medicine.

 Check for a medication error.

Managing ADRs
.Step 3. Take corrective and follow-up action.
Corrective action will depend on cause and severity

 Severe ADRs
 Educate and monitor prescribers.
 Change the formulary or standard treatment guideline if
necessary to substitute a medicine that is safer or that is easier to
use by staff.
 Modify patient monitoring procedures.
 Notify drug regulatory authorities and manufacturers.

 All ADRs
 Educate and warn patients.
Prevention of ADRs
Schematic of preventable and unavoidable
adverse events

Known ADRs and Side Medication and Product

Effects Device Error Defects

Unavoidable Avoidable

Preventable
Adverse
Events
Remaining
Uncertainties:
· Unexpected
ADRs and side
Injury or Death effects
· Unstudied uses
· Unstudied
populations
DTC's Role in Preventing ADRs
 Review ADR reports regularly and inform professional staff of the
incidence and impact of ADRs in the region.
 Discuss changes in the formulary or standard treatment guidelines for
significant or recurring problems with ADRs.
 Educate staff, especially providers, concerning ADRs.
 Identify medicines on the formulary that are “high risk” and should be
monitored closely by physicians and pharmacists.
 Identify “high-risk” patient populations, including pregnant women,
breast-feeding women, the elderly, children, and patients with renal or
liver dysfunction; close monitoring of these patient populations by
physicians and pharmacists will help prevent serious adverse
reactions.
 Review medication errors and product quality complaints to ensure
they are not contributing to the incidence of ADR at the hospital.
Adverse Drug Events (1)
 An adverse drug event is any untoward
medical occurrence that may be present
during treatment with a medicine but does
not necessarily have a causal relationship
with this treatment.

 Adverse drug events include medication

errors.
 Adverse Drug Events (2)*
 Record review of 15,000
inpatients in 1992
 Adverse events 2.9% (30%
due to negligence)
 55% adverse events were
non-operative; 19% were
due to medicines
 0.56% adverse drug events
 35% drug adverse events
due to negligence
*Thomas, E.J., D.M. Studdert, H.R. Burstin, et al. 2000. Incidence and Types of Adverse Events and
Negligent Care in Utah and Colorado. Medical Care 38(3):261–271.
 Primary medicines involved were
antibiotics (25%), cardiovascular
medicines (17%), analgesics (9%),
and anticoagulants (9%)
 Types of medicine use error—
 Wrong medicine prescribed (21%)
 Prescribed despite known allergy
(6%)
 Incorrect frequency (5%)
 Wrong dose (8%)
 Missed dose (5%)
 Medicine interaction (3%)
 Causes of Adverse Drug Events*
 Record review of 4,031 inpatients
 247 (6.1%) adverse drug events; 70 (28%) preventable
 194 (4.8%) additional errors without patient harm detected
 264 errors were due to—
 Physician ordering (39%)
 Transcription (12%)
 Nurse administration (38%)
 Pharmacy dispensing (11%)
 Reasons for error included—
 Lack of prescriber knowledge (37%)
 Inadequate checking of medicine identity or dose (15%)
 Incomplete patient information (14%)
 Inaccurate transcription (11%)
 Failure to note medicine allergy information (9%)
*Bates, D.W., D.J. Cullen, N. Laird, et al. 1995. Incidence of Adverse Drug Events and Potential Adverse
Drug Events. Implications for Prevention. ADE Prevention Study Group. JAMA 274(1):29–34.
 Cost of Adverse Drug Events*
 Record review of 4,031 inpatients re-analyzed by case
control
 Comparison controlling for level of care, severity, and
co-morbidity (paired regression)

 247 adverse drug events were estimated to have—

 Extended hospitalization by 2.2 days
 Increased cost of 3,244 U.S. dollars (USD)

 70 adverse drug events due to errors were estimated

to have—
 Extended hospitalization by 4.6 days
 Increased cost of USD 5,857
Bates, D.W., N. Spell, and D.J. Cullen. 1997. The Costs of Adverse Drug Events in Hospitalized Patients.
ADS Study Group. JAMA 277(4):307–311.
Medication Errors (1)
 Administration of medicine or dose that differs
from written order
 Medicine prescribed but not given
 Administration of a medicine not prescribed
 Medicine given to the wrong patient
 Wrong medicine or IV fluid administered
 Wrong dose or strength given
 Wrong dosage form given
Medication Errors (2)
 Medicine given for wrong duration
 Wrong preparation of a dose (e.g., incorrect
dilution)
 Incorrect administration technique (e.g.,
unsterile injection)
 Medicine given to a patient with known allergy
 Wrong route of administration used
 Wrong time or frequency of administration
Causes of Medication Errors
 Human factors
 Heavy staff workload and fatigue
 Inexperience, lack of training, poor handwriting, and oral orders

 Workplace factors
 Poor lighting, noise, interruptions, excessive workload

 Pharmaceutical factors
 Excessive prescribing
 Confusing medicine nomenclature, packaging, or labeling
 Increased number or quantity of medicines per patient
 Frequency and complexity of calculations needed to prescribe,
dispense, or administer a medicine
 Lack of effective policies and procedures
When Medication Errors Occur (1)
Medicine Ordering or Prescribing

Transcribing

Dispensing

MEDICATION
Administering
ERROR

Monitoring
 When Medication Errors Occur (2)
Medicine Ordering or Prescribing 77.8%

Transcribing 5.8%

Dispensing 1.0%
MEDICATION
ERROR
Administering 12.8%

Fortescue E.B., et al. 2003. Prioritizing Strategies for Preventing Medication Errors Monitoring 0.5%
and Adverse Drug Events in Pediatric Inpatients. Pediatrics 111:722–29.
Preventing Medication Errors (1)
 Establish consensus group of physicians, nurses,
and pharmacists to select best practices

 Introduce a punishment-free system to collect and

record information about medication-related errors

 Develop written procedures with guidelines and

checklists for IV fluids and high-risk medicines
(e.g., insulin, heparin, narcotics)
Preventing Medication Errors (2)
 Require legible handwriting and complete spelling of
medicine name
 Use standardized notation
 Doses given in mg, mcg, g
 Leading zero used for values < 1 and no trailing zero (e.g., 0.2 mg
instead .2 mg; 2 mg instead of 2.0 mg)

 Write route of administration on all orders

 Write out directions completely (e.g., “daily” not “QD” or
“OD”)
Preventing Medication Errors (3)
 Limit use of telephone and oral orders to emergency
situations
 Confirm identity of patients before administering
medication
 Use standard administration times for hospitalized
patients
 For look alike and sound alike names, establish a policy
requiring that prescribers write both brand and generic
names
 Use pharmacy staff to help prevent errors
Using Pharmacists to Prevent Errors
 New York, USA*
 Pharmacists assigned to monitor medication orders
 Detected and corrected 2,103 significant errors during one
year (4 errors/1,000 medication orders)

 Massachusetts, USA**
 Pharmacists assigned to make rounds with the intensive care
unit team
 Made 366 recommendations on medicines; 362 accepted
 Reduction in preventable adverse drug events due to
prescribing errors from 10.4 to 3.5 per 1,000 patient-days
*Dean, B., M. Schachter, C. Vincent, et al. 1998. Causes of Prescribing Errors in Hospital Inpatients:
a Prospective Study. Lancet 359 (9315):1373–78.
**Leape, L.L., D.J. Cullen, M.D. Clapp, et al. Pharmacist Participation on Physician Rounds and
Adverse Drug Events in the Intensive Care Unit. JAMA 282(3):267–70.
Activities
Activity 1
 Case history: Penicillin Anaphylaxis Reported

Activity 2
 Case history: Acute Respiratory Infection in a Two-
Year Old

Activity 3
 Serious ADRs with Phen-Fen Combination
Medicine
Summary (1)
 DTCs can contribute significantly to improved
medicine safety by—

 Assessing the safety of all new medicines before

placing on the formulary

 Implementing systems to monitor the occurrence

of ADRs

 Managing and evaluating suspected ADRs,

assigning causality, and taking corrective action
when necessary
Summary (2)
 Reporting ADRs to regulatory authorities and
manufacturers

 Preventing the occurrence of ADRs and events

by—
 ADR monitoring and reporting
 Careful evaluation of patients before prescribing,
especially high-risk patients
 Educate staff